Bringing the injured back to work

Most of you reading this article probably work in facilities with return-to-work programs. According to studies, 70 to 80 percent of companies have procedures to get injured workers back on the job. And companies have used these programs more aggressively in recent years to lower workers' compensation costs.

For example, the Bureau of Labor Statistics released data last December showing declines in virtually all the major occupational injury and illness rates except for one-cases involving restricted work activity. Since the mid-1980s, more and more injured employees have been brought back to the job before they are fully healed to perform some type of restricted work-perhaps shortened hours, a temporary job change, or modifications to their regular job (such as no heavy lifting).

This is especially true in manufacturing, where comp costs hit hard. The rate of restricted work cases in manufacturing in 1996 was 2.4 per 100 full-time workers, more than double the national average.

"There's a real big push to get people back on the job," says Peg Seminario, safety and health director of the AFL-CIO.

"We've seen an enormous explosion in return-to-work programs," echoes Nancy Lessin, senior policy analyst with the Massachusetts Coalition for Occupational Safety and Health. Both Seminario and Lessin sit on OSHA's national advisory board.

The emphasis has paid off. Getting injured employees back on the job, together with rigorous injury and illness case management and more serious attention to safety training in general, has put the brakes on runaway workers' compensation costs. Comp payments across industry have declined in the 1990s after grabbing headlines-and management's attention-by skyrocketing in the 1980s.

For example, from 1985 to 1992, workers' compensation costs grew at an annual rate of nearly 15 percent, according to the Social Security Administration. But from 1992 to 1995, workers' comp health care expenses per worker decreased annually at a rate of about five percent. And between 1995 and 1996, 20 states reported declines in comp cases filed. Only five states surveyed reported increases.

But with success has come controversy. "Some return-to-work programs are legitimate, too many are not," says Lessin. She talks of a Midwest company that has someone drive injured employees to work to play cards-and to stay clear of the comp system.

Emotional pitfalls

Returning an injured employee to the job is a delicate issue. Delicate enough that return-to-work programs have their own form of political correctness.

"Don't call it 'aggressive' return to work or 'early' return to work," says one occupational health nurse. "Aggressive" sounds adversarial, as though employers are badgering injured employees. "Early" implies that the injured are being rushed back to work.

"Light-duty" work is also out of favor. It can imply that injured employees are getting off lightly. This can brew dissension among coworkers, and make supervisors think any return-to-work attempt is not productive. "Restricted," "transitional," or "modified-duty" work are more popular terms today, carrying less negative connotations.

Professionals interviewed for this article were careful in how they talked about return-to-work programs. The issue is indeed emotionally charged. For example:

Injured workers can have psychological scars caused by a workplace incident serious enough to keep them home. Maybe they feel they let their employer down by getting hurt. Maybe they blame coworkers. Perhaps they deny any responsibility. They can be anxious about an investigation of the incident, about returning to their old job and getting hurt again. Then the phone rings at home and a supervisor from work asks, "So when are you coming back?"

If not handled properly, an injured employee can feel harassed, exploited, or humiliated. Can he or she trust the employer's intentions? What's the real agenda: cost-cutting or concern for personal welfare? Plus, can the employer be trusted to find meaningful "transitional" work that won't embarrass or reinjure the employee?

The employer, meanwhile, might think he has a problem on his hands. "Seventy-five percent of the people who have accidents have negative attitudes to begin with, that's why they got hurt. They don't follow rules," says one long-time safety practitioner.

Injured workers might be careless and lazy in the eyes of employers. They, too, can fear being ripped off-by victims with bad work habits who exaggerate injury claims.

Employers can have other concerns, too. What's their liability if the injured worker returns and gets hurt again? Or will that employee become hooked on light-duty work and drag out his recovery? Will coworkers report injuries so they can get light-duty jobs?

Coworkers are not disinterested parties to return-to-work efforts. Some may resent having to pick up the slack for someone injured, especially if that person is back at work playing cards or simply doing "make-work." Is the company playing favorites-making life easy for injured star performers while ignoring others' cases?

The attending physician or other health care professional can also have suspicions. Is the company trying to rush their patient back to work?

An injured employee's immediate supervisor has his own feelings on the matter. He might simply resist the employee coming back if not 100-percent fit. Perhaps he was burned in the past by someone who got re-injured. Or he just doesn't have time to "find work" for someone coming back early. The last thing he needs is a tap on the shoulder one hectic morning and the question: "Jack's coming back to work with a broken arm. Can you find something for him to do?"

"Let human resources worry about this stuff," he might bark back.

"Supervisors can look at return-to-work as coddling," says safety consultant Ray Colvin. Or a waste of time that's not worth the effort.

Practical barriers

A supervisor's concerns bring out the practical, as well as emotional, issues surrounding return-to-work programs. To do it right, return-to-work efforts are time-consuming, especially when you're starting them up. Policies must be written. Teams are often formed to decide on various protocols and procedures. There can be many phone calls, faxes, and meetings with lawyers, insurance carriers, management, employees, and nearby medical clinics or local family physicians.

In addition, jobs should be evaluated to determine if, and how, they can be done by an employee with medical restrictions. "Oh my gosh, you want me to look at all my jobs," is a common reaction, according to one occupational health specialist.

Then there is the education process. Managers, supervisors, and all employees should be instructed about return-to-work procedures, and why they are necessary.

All this needs to be done proactively, say the experts, before a spat of injuries, one very serious incident, or excessive workers' comp costs force a hasty reaction. It's never been easy for safety and health practitioners to convince an organization to commit this kind of time and effort in the absence of a clear and present problem.

So how do you do it? Read on for tips for getting the support of managers and supervisors, addressing employees' concerns, drafting a policy, evaluating jobs, and some other keys to success.

Digging for data

For starters, perhaps you have a problem and don't know it. "You've got to know your numbers, the costs that can be contained," says Margaret Lynn Howe, RN, medical director for the Michigan Plastic Processors Association's Workers' Compensation Fund.

Between eight to 17 percent of a company's payroll can go to compensating for time away from work, says Deborah DiBenedetto, a senior consultant for workers' compensation for Watson Wyatt & Co. The direct costs of disabilities (short- and long-term disability, medical treatment, sick leave, salary continuation) account for six to 12 percent of payroll; indirect costs (training replacement workers, lost productivity, and so on) account for one to four percent; and disability management administrative costs account for one percent, according to the 1997 "Absence Management Survey" conducted by Commerce Clearing House.

Selling management

Top management, whose interest or disinterest in return-to-work will make or break programs, wants to see costs and a return on investment. You might start by checking if your injury and illness statistics follow the national norm. According to the Bureau of Labor Statistics, 45 percent of all occupational injuries and illnesses in 1996 required recuperation away from work, restricted duties at work, or both. Do nearly half of your injuries result in some form of lost time? That's an obvious financial drain.

Next, look for evidence showing how return-to-work programs can make a bottom line difference. After Howe's association initiated a return-to-work program for the more than 80 companies it insures, wages paid as part of workers' compensation dropped from $3 million for all members to $1 million in five years, she says.

"The total number of claims hasn't gone down for us. It's remained pretty consistent. But the cost per claim has gone down dramatically because of wage savings. Our number of lost-time claims has gone down," says Howe.

Managers also need to understand that return-to-work programs target short-duration injuries that can otherwise slip through the system-and cost money. Howe estimates the average lost-time claim involves three to six days off the job. The cost of these cases adds up. Plus, managers should know that transitional work assignments in most cases will not drag on to affect productivity.

Experts also say return-to-work programs should be presented as another type of employee benefit, a recruiting tool. "This is a softer sell, but return-to-work is a human resources issue," says Roger Moseley, CEO and president of Great States Insurance Co. "It sends a message that employees are valued. That's important in today's employment market, where companies are competing for employees."

Motivating supervisors

The economics of return-to-work are also part of selling supervisors. Their involvement is as critical as top management's, according to experts. Moseley advises: "Tell the supervisor, 'Look, you've invested time and energy training your people. What happens to your production schedule if they get hurt? Isn't it better to bring them back to their jobs, maybe with some help?'"

Supervisors must understand what's in it for them, says Howe. It's to their advantage to have a knowledgeable, skilled worker contributing in some capacity, compared to hiring a temporary worker who must go through the learning process, she says.

What if the injured worker isn't one of the supervisor's star performers, but one of those so-called "attitude problems" that the supervisor would rather ignore and leave at home? Says one health professional: "In that case, I tell the supervisor, 'So you're going to reward that person by paying them to stay home? They're winning and you're losing.' You use whatever you have to sell."

Addressing employee concerns

What about selling employees on return-to-work? The key here is to let every employee know upfront, preferably when they're first hired, that return-to-work is a company policy and expectation in most cases, say experts. They should understand the procedures, know what kind of transitional jobs have been identified, and the rationale behind the program.

That rationale can be discussed in two ways, according to experts. First, be honest about the need to contain costs. Says Moseley: "Tell employees, 'Sure we're concerned about costs and production. We're a business, and it's important for us to stay alive as a business. We need you to be productive.'"

Second, point out that medical approaches to disability recovery and rehabilitation have changed. Patients in hospitals today are up and about sooner after surgery. Athletes return to action sooner through aggressive treatments.

The idea that injured people should rest until they're 100-percent fit has been replaced by the belief that "activity is better than inactivity," as Howe states. She says orthopedic physicians have learned that patients who didn't follow orders to stay off their feet often recovered sooner than those who did, she says.

"return-to-work is not just about cost-cutting. You've got to move the body. If you're not moving you're not bringing oxygen to the tissues that need it. You're not getting proper circulation. Muscles tighten up and shorten. To be moving is to be healthy," says Howe.

Finally, employees must be assured that the company will act responsibly. There must be real jobs, not fake or punitive ones, for injured workers, says Howe. And there must be assurances that managers and supervisors will listen to medical providers and the concerns of employees.

"Tell employees, 'No, we're not going to make you come back too early'," says Moseley. "'We won't do anything before the doctor says it's OK. And we'll work with you to build temporary jobs.'"

Putting it in writing

Such assurances need to be documented in a policy distributed to all managers, supervisors, and employees, say experts. Policies should remove as much ambiguity as possible from return-to-work issues.

For example, Joan Davis, RN, corporate manager of occupational health for MedPartners, Inc., is in the process of drafting a new policy for her organization. Her policy defines "modified duty," spells out responsibilities, and sets requirements and guidelines. Employees, working with their doctors, are responsible for communicating their work ability and restrictions. If an injured employee is able to return-to-work, as verified by his or her physician, local facility managers are to review work demands and attempt to accommodate any restricted abilities. Assignments must be adhere to the restrictions and limitations. They must be time-specific, designed to return the employee to eventual full capacity, and be monitored to assure the well-being of the employee.

In particular, Davis suggests that any modified duty continuing beyond 90 days should be carefully supervised to make sure that actual or anticipated improvement of the employee's condition is occurring.

Policies, even detailed ones, can collect dust without a strong commitment behind them. Davis asserts that the key to successful job re-entry is to ensure that a "committed professional is available to coordinate and communicate exactly what any restrictions are and how these restrictions will match the modified-duty assignments." Someone must mind the store.

Finding modified jobs

Davis recommends that supervisors, working with human resources and employee health personnel, should provide employees' physicians with current job descriptions that include any physical job demands. Supervisors are encouraged to consider how to accommodate medical restrictions, and to communicate modified duty possibilities to the treating physician.

"This is the point where supervisors can get pale on you," says an occupational health specialist. It's a daunting task to catalog every job in a company. But there are ways to minimize the challenge.

You don't have to start by tackling every single job, say experts. To prioritize, use your own injury records, or statistics from your industry, to determine the top 10 or 15 jobs that most often experience injuries. Or, see if you can group similar jobs into general categories. You might be able to take 100 jobs and end up with 15 classifications.

Then, you can use a checklist format to delve into the details of these jobs. Does the job involve repetitive movements? How often? Is there grasping or pinching? Walking? If so, what distances? On level or uneven surfaces? Is there lifting involved in the job? What is the weight of the loads? What's the frequency of lifting? Does the job involve sitting? Standing? For how long? Is there exposure to heat, noise, or chemicals? Does the job involve working with machinery, operating a moving vehicle? What about wearing personal protective equipment?

This is where many return-to-work programs come up short, according to experts. After all, who has the time to catalog such specifics? And there are fears that the information, once documented, might come back to haunt a company in disability discrimination cases or OSHA investigations.

But experts say a one-time assessment (allowing for reviews if jobs change) done by supervisors with employee input or validation has numerous benefits. First, it takes the subjectivity out of describing a job. "When an employee is injured and the doctor asks what he does on the job, that's not the best time for a description," says an occupational health specialist. A detailed job description also makes it much easier for the medical provider to respond with clear, specific restrictions for returning to work.

Beyond facilitating return-to-work, job evaluations can reveal:

Previously untracked injury trends;

So-called "critical job behaviors" that should be the focus of safety training;

Essential job functions that need to be identified for compliance with Americans with Disabilities Act requirements;

Ergonomic and/or industrial hygiene hazards;

Problems affecting product quality or overall productivity.

Final thoughts

Experts interviewed for this article offered three additional points that will affect the success of your return-to-work program:

1. Know when to back off-not every injured employee can return-to-work. "Even if the doctor says it's OK to return, some people just can't," says Howe. "Maybe the person has ten medical conditions and this injury is the eleventh. Maybe their life is on the edge, maybe their family is falling apart. Some people can't work through pain. Some don't have the fight in them to come back. Ninety-five percent will work; you have to recognize the ones who won't and put your energy where it's worth it."

2. The hardest part of a return-to-work program is setting it up, says Howe. Fears, fights, and confusion will subside after everyone adjusts to the procedures. But it takes constant communication. And you can never put the program on automatic pilot, says Howe. Someone must be designated and committed to monitoring it.

3. Many of the key elements of a return-to-work program are found in successful safety and health programs-management and supervisory support, employee involvement and education, mutual trust, policies and procedures, communication and coordination, designated responsibilities and accountability. In fact, says consultant Ray Colvin, "If you don't have a good safety and health program, you can't possibly have a good return-to-work program."

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